Bereavement Intervention in Complicated Grief


Grief is a painful reaction to a loss usually of a great magnitude. This painful reaction may cause emotional changes that may affect the health of an individual. Various researches have been done on the topic of grief and bereavement. This has led to the formulation of various theories that try to explain why a loss considered to be of a high magnitude has the effects of causing grief. To avoid many complications in the process of accepting death, it is suggested that the reality of death be made clear to the individuals (Currier, Holland and Neimeyer, 2007).

In his contribution to the subject of bereavement, Sigmund Freud came up with a psychoanalysis model for bereavement. This theory by Freud has been challenged by other theorists who question its effectiveness due to lack of supporting empirical information. Some of the theorists have analyzed the theory put across by Freud and have found no evidence of empirical information on the five concepts proposed by the work of Freud (Littlea, Sandlerb and Wolchikb, 2008).

Such concepts include the idea that distress is inevitable, it is necessary, the benefits of working through loss, recovery expectations and the arrival of the resolution state. In other works, on grief, the types of behavior exhibited by individuals experiencing grief were measured (Cohen, Mannarino and Deblinger, 2006). However, very little evidence on the effectiveness of working through grief to cope with the death situation was found.

Some theorists have also come up with the suggestion that maintenance of emotional or psychological bond with the deceased should not be taken as an indication of existence of a problem in the process of grieving. In any case, modern approaches encourage maintenance of the psychological bond by the bereaved in order to help him to cope with the grief (Fiorini and Mullen, 2006). However, this is in contrasts to the traditional view that encourages the severance of the bond by the bereaved.

Theories of Grief

Many theories have been suggested to explain the causes of grief. These theories include the attachment theory, the cognitive theory among others.

Attachment Theory

The attachment theory tries to explain the effects of bereavement as having their origin from the disruption of bonds between the deceased and the bereaved. It also states that effects on the bereavement can also be explained through the ways different individuals respond to the death of a person considered to be significant in their lives (Lieberman et. al 2003). According to this theory, much of complicated grief arises from the severance of a bond considered to enhance the sense of security. Researchers in the area have, however, indicated that it is possible for insecure attachments to prevent the possibility of continued existence of the bond by the bereaved on the deceased.

Meaning Reconstruction Theory and Cognitive Stress Theory

The meaning reconstruction theory, on the other hand, suggests that bereavement effects arise from an individual’s effort to make the meaning out of the loss of an emotionally attached person (Webb, 2000). This meaning is considered to be based on the interpretation of an individual and also his beliefs. On the other hand, cognitive stress theory seeks to object the traditional view on bereavement (Oaklander, 2000).

Whereas cognitive stress theory recognizes the importance of the positive emotions during bereavement, the traditional views consider the review of the negative views as being important in the process of recovering from loss. The negative emotions constitute mourning and are thought to assist bereaved to accept the loss caused by death and also to cut the bond that initially existed between the bereaved and the deceased (Elsevier, 2011). However, this view has been relegated in favor of the view that positive emotions can also help an individual to recover from loss of an emotionally attached individual.

The Dual Process Model

Another view has been proposed by the dual process model which proposes two types of stressors that give effects to the bereavement. The stressors suggested by this model are loss and restoration oriented stressors (Geller 2010). The loss oriented stressor involves the behavior of the deceased to focus the events that led to the death and also a focus on the deceased. On the other hand, the restoration oriented stressor deals with issues to do with minor stressors such as management of family finance. According to this model, an individual will oscillate between these two stressors as he tries to focus on the deceased and also to cope up with the challenges that might arise as the consequences of death (Worden, 2008).

The degree to which an individual will engage in either of the two orientations depends on a number of factors which will include expectations of the society, cultural practices and the personality of the bereaved.

Two types of bereavement are considered to exist. There is bereavement that is considered to be uncomplicated while the other type is considered to be complicated. Further classification divides complicated bereavement into complications as a result of death and also as a result of stigma (Worden, 2001). Uncomplicated bereavement is considered to be the normal grief that a person experiences after the loss of a close relation. In cases of children especially the parented ones, uncomplicated bereavement does not pose a threat of possible future mental condition (Leming and Dickinson, 2010). However, in cases involving both forms of complicated bereavement, chances of future development of psychopathology, by a child are high.

Various methods should be used to help children cope with bereavement. Some of the methods that can be used include the play therapy, group therapy and the cognitive behavior therapy. The main issues that should be addressed in trying to intervene include the provision of information for the child on death and bereavement (Wright, 2011). This is necessary in order to avoid the misunderstanding of the issue due to childhood inefficiencies. The second issue should focus on the loss while the last one should focus on the child’s memory.

Grief interventions are categorized into three; primary preventive, secondary preventive and tertiary preventive approaches (Agnew, 2010). Primary preventive measures target those people who are experiencing normal bereavement while secondary preventive approaches focus on those at a risk of experiencing bereavement related repercussions. Tertiary is for those experiencing the full blown problems associated with bereavement (Wagner & Maerecker, 2006).

The death of a loved one is the most traumatizing event that one can face. It normally precipitates into depression, anxiety, panic, escapist tendencies such as alcohol abuse among other immediate coping choices. Primary intervention employs psychological techniques such as establishing good relations and listening actively. This primary care is essential to avoid immediate traumatic events and guilty conscience of a thing one could or could not prevent from taking place. It offers consolation in times of urgency (Maerecker et al, 2008).

A primary preventive measure aims at working with the death issue, which is more depressing than any other psycho-emotional events. It helps the bereaved cope with death in the most harmonized way. Primary bereavement leans towards providing the necessary support, establishing a good rapport, letting the bereaved talk freely and express emotions (Kersting, Bra¨hler, Glaesmer & Wagner, 2011). More focus is put on what the bereaved believes in relation to the loss of a loved one (Bennett, Gibbons and Mackenzie, 2011). It also creates an attitude that makes them feel detached from the cause of death. It is rather an integrative approach that helps the affected fit back in the society through social relationship (Lin et al, 2004).

The intervention strategies centers in relating with the bereaved. This also includes a one-on-one interaction with the bereaved. The bereaved should be given more time and space to adapt to change. The care offered is unidirectional; one person being very sensitive and attentive at the same time. Offering empathy rather than sympathy is crucial in the primary preventive care. More emphasis is put to explain that the bereaved feelings are normal and validating what they feel. In the last phase of preventive care, the bereaved is oriented and counseled not to make radical decisions (Linduer et al, 2011).

Secondary preventive measures diagnoses complicated stage of grief and recommends a therapy to the bereaved. It may also include counseling the bereaved. The complicated grief includes chronic depression, anxiety and stress related to death. Some of these reactions do not affect the bereaved in isolation, but rather may coexist or even overlap one another. Complicated grief is the repetitive pre occupation with the deceased, reconnection with the deceased. The implication of complicated grief leads to psychotherapy and psychopharmacology approaches (Bonano & Lalande, 2005).

Psychopathological bereavement involves distorted thinking that one get after the death of a loved one. It results to automatic thoughts of an individual and other mental evaluation (Kerstin et al, 2011). Grief therapy is aimed at helping the bereaved to walk through the storm and reach heightened life resumption, it facilitates full life restoration. A psychotherapy intervention involves using a group therapy. Group therapy aims at facilitating the bereaved insight about the repetitive self-conflicts that are associated with the sudden loss of a beloved one. It helps the bereaved adapt to life as soon as possible. It relies on the principle that problem solving can be effected through the provision of continued support (Kaltman & Bonano, 2003).

Complicated grief can also be treated through the use of integrative cognitive behavioral treatment which is done through three to five diagnostic sessions. In the stabilization process, patients are helped to reconstruct their lives and finally fit in the daily routine programs (Currier, Neameyer & Berman, 2008). This therapy may also involve redefining the routine roles of the affected. The changes of task after one has died are reversed.

Patients are encouraged to refocus their lives so as to disconnect with the deceased. Affected parties are advised to replace negative thoughts with more neutral ones. Cognitive restructuring may also involve relating and playing with cognition, behavior and emotion. It extends its influence in eliminating the hallucinated details. Patients are advised to let go of details of the terrible imaginary. Psycho education and motivation driven change help in the renewal and restructuring (Boelen & Van Den Bout, 2005).

Tertiary preventive measures focus on counseling patients with grief issues. It is put into effect for people who have been extremely traumatized. Pharmacotherapy is used to treat these extreme cases (Boelen, De Keijser & Van Den Hout, 2007). The therapy involves administering of drugs to patients with grave symptoms. Some of the drugs used include paroxetine and nortirptyline. People with psychiatric disorders suffer from acute bereavement. An increase in depressive symptoms arouses clinical importance which leads to psychiatric disorders. This particularly happens when the post-trauma has been massive and huge. Formal interventions are also employed. They include individual, group or family- based therapies (Ungureanu & Sandberg, 2010).

Medication proves to be the best option in the treatment of depression, as opposed to psychotherapy. The uses of the two drugs aforementioned have a significant effect in reducing depression. The symptomatic levels of depression declines by over a half when the drugs are administered (Maercker, 2008). Use of support groups and counseling can play a crucial role in preventing tertiary depression. This also allows for a significant decline in distress (Kirwin & Hamrin, 2005).

Psychotherapy-led intervention measures are also employed. Like in complicated grief, group therapy proves to be effective in the post trauma management. Touch therapies are also applied to mothers who have experienced child loss. The therapy is known to reduce grief significantly. The touch is usually gentle and gives balance to the body and the mind (Boelen et al, 2008).

Complicated Verses Normal Grief

Normal Grief

Normal grief arises when people are deeply saddened by a sudden grief for a particular period of time of about two weeks (Prigerson, & Maciejewski, 2006). For a normal grief to result a cause must be known and no correlation with self-esteem (Stroebe & Schut, 2006). As time goes by, the reaction to the loss declines and the person is engaged back to daily routines (Ott, 2003). During the integration of the bereaved person to his daily activities, the thoughts and painful feeling of the loss ceases from dominating his mind (Prigerson & Maciejewski, 2006). Normal grief is not found in the minority groups of people. Only an estimated number of 10-20 percent find coping painful and difficult (Horowitz et al, 2003). This is because integration of the loss does not occur and acute grief is extended as a complicated grief.

The individuals suffering from complicated grief experiences continued and disturbing disbelief of the death (Langner & Maercker, 2005; Lindauer et al, 2005). The bereaved yearn and long the deceased and continually suffer from painful emotions and cramps of intense magnitude (Dillen, Fontaine & Verhofstadt-Denève, 2008). Thoughts related to the death which are distressing and disturbing of the loved one remain occupying the mind of the bereaved (Boelen & Bout, 2008; Horowitz et al, 2003). There is also loss of interest in the ongoing life.

In normal grief, an individual struggles to accept the reality of life after the loss of the deceased. He or she wishes to protest the death and some have feeling of bitterness (Prigerson & Maciejewski, 2006). Some individuals suffer from somatic distress (Hogan, Worden & Schmidt, 2004). The symptoms of an individual suffering from normal grief include a sense of adjusted loss, persistence of emotional loneliness and hallucinatory appearance of the deceased (Prigerson, & Maciejewski, 2006). There is also a surge of grief in response to calendar days or other reminders of the loss and memories of the deceased person being present in the mind of the bereaved (Hogan, Worden & Schmidt, 2004).

Complicated Grief

Complicated grief arises from the disruption of the normal grief process which forbid healthy ending and healing of the affected individual (Hogan, Worden & Schmidt, 2004). It is also referred to as chronic or distorted grief. There are various types of complicated grief. This includes prolonged grief also called chronic grief (Dillen, Fontaine & Verhofstadt-Denève, 2008). This type of grief is easily recognized due to its lengthy existence.

A person is often stuck somewhere in his grief, and he cannot see the end of it (Hogan, Worden & Schmidt, 2004). Absent grief referred to as masked grief results from lack of obvious expression of grief and the loss of the deceased warrants it, for example, when a husband loss his wife as a result of death (Ott, 2003). Distorted grief rarely occurs, but when it does occur, it is usually manifested in persons who have an underlying pathology (Zhang, El-Jawahri, & Prigerson, 2006; Lin et al, 2005). In complicated grief, complications remain after the loss for a longer period of time (Ott, 2003).

It comprises of strong symptoms of longing for the deceased, continued thoughts or images of him, feeling intense loneliness and feeling that a life without the person is meaningless. Delayed grief occurs from absent grief, which arrives at a later date (Zhang, El-Jawahri, & Prigerson, 2006). It is accompanied by intense emotions. Most people suffering from delayed grief suffer from depression (Dillen, Fontaine & Verhofstadt-Denève, 2008).

Another type of complicated grief is the excessive grief. This type hits with strong emotions accompanied with frightening symptoms that overwhelm the bereaved. The bereaved appear to be traumatized, out of control and need a great attention (Stroebe & Schut, 2006). According to Lichtenthal, Cruess and Prigerson (2004), complicated grief has two symptoms. One is the symptoms of separation distress.

This may include yearning and searching for the deceased, loneliness and preoccupation of the mind with thoughts of the deceased. The other symptom is traumatic distress (Boelen & Bout, 2008). This comprises of feelings of disbelief, mistrust, anger detachment from others and experience of somatic symptoms of the deceased (Boelen & Bout, 2008). Complicated grief is associated with clinically important distress and impairment in various areas such as work, social functions, sleep disturbance, disruption in daily routines and impairment in functioning relationships (Kimberly, Elhai & Gray, 2007).

In 2003, Horowitz et al asserted that the nature of the cause of death as well as the circumstances that surrounds the nature and the cause of death of someone significant exacerbates the risk of development of complicated grief. There is also the risk of disorder occurrence after the death which is traumatic such as premature, sudden or unexpected (Lichtenthal, Cruess & Prigerson, 2004). Normal grief is also reported to cause complicated grief depending on how the person reacts to the loss. The risk of developing complicated grief is further complicated by a person’s past history where individuals who have shown tendencies of poor coping habits are at a higher risk of developing complicated grief (Hardison, Neimeyer & Lichstein, 2005).

Thus, people with past medical history of issues such as depression, personality disorders nervousness among other behavioral illnesses has a higher chance of developing complicated or traumatic grief (Kimberly, Elhai & Gray, 2007)


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